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Objective: Prehospital bypass policies were designed to encourage transport of eligible stroke patients to stroke centers in order to receive rapid assessment and treatment. In a national dataset we examined the relationship between implementation of bypass policies and the proportion of patients transported to stroke centers. Methods: We included EMS transported ischemic stroke patients aged 66+ from a 20% sample of Medicare claims (2007 - 2014). We excluded patients not admitted through the ED, and those not continuously enrolled in parts A/B in the prior year. The outcome measure was transport to PSC. Stroke certification status was validated by multiple stroke certification databases; policy implementation details were obtained from review of statutes and regulations. We employed difference-in-differences (DID) analyses with a state-level random intercept. Results: A total of 20,345 patients were included in the study with 7,239 from policy states and counties and 13,106 from non-policy states and counties. The proportion of patients arriving at PSCs increased from 28% to 43% in non-policy areas and 33% to 57% in policy areas. The DID analysis revealed a net effect of 11% (p Discussion: In pre-thrombectomy era, statewide prehospital bypass policies were related to significant increases in proportion of stroke patients transported to stroke centers. Future analyses will assess if these effects occur in the thrombectomy era, and if these policies influence delivery of stroke treatments.

To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.Veterans Affairs (VA) and Medicare data.We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental health care utilization.We extracted data for 130,704 VA patients ≥65 years old with a hospitalization risk ≥90th percentile and ≥ four outpatient visits in the baseline year.The mean (SD) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI = 1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively).Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers, and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.

Introduction: Endoscopic Vein Harvesting (EVH) provides comparable rates in major adverse cardiac events to Open Vein Harvest (OVH) based on the intermediate-term results of the REGROUP Trial. Value based purchasing places more pressure to examine whether minimally invasive techniques, e.g., EVH, yield intended or unintended economic effects. The objective of this study was to compare health care costs between participants randomized to EVH or OVH during coronary artery bypass graft (CABG) surgery in the REGROUP trial. Hypothesis: We hypothesized that EVH would result in lower discharge and follow-up costs compared to the traditional OVH. Methods: Department of Veterans Affairs Cooperative Studies Program #588 (Clinicaltrials.gov NCT01850082) randomized 1150 participants (574 OVH, 576 EVH) at 16 VA medical centers. We linked participants to VA administrative data in VA’s Corporate Data Warehouse and extracted activity-based cost data starting with the index surgery. We analyzed discharge costs for the index surgery as well as follow-up costs in 30-day periods for EVH vs. OVH, comparing results from different statistical models to test for robustness. All costs were standardized to 2020 US dollars. Results: The unadjusted average cost for CABG patients with EVH and OVH was $76,607 (SD $43,883) and $75,368 (SD $45,900), respectively; the costs include both facility and provider costs. Despite the skewed variation in costs, there were no significant differences in discharge costs and high-cost patients were equally likely in both groups. We also found no significant differences in follow-up costs; the average follow-up period was 33 months (maximum follow-up was 85 months). The results were highly robust to the statistical model. Conclusions: Endoscopic harvesting was not associated with a reduction in costs for the index CABG surgery or follow-up care, nor was it associated with increased costs through unintended events. Therefore, the choice to provide endoscopic harvesting should be based on surgeon and patient preferences.

Introduction: The Centers for Disease Control and Prevention (CDC) National Amyotrophic Lateral Sclerosis (ALS) Registry is the first national registry for a chronic neurologic disease in the USA and uses a combination of case-finding methods including administrative healthcare data and patient self-registration. Methods: We applied capture-recapture methodology to estimate the completeness of the Registry for ascertaining patients with ALS for the first full year and the fourth year of the Registry (2011, 2014). The Registry uses the combination of two national administrative claims databases (Medicare and Veterans Affairs) with a self-register option at the registry portal. We conducted descriptive analyses of the demographic and clinical characteristics of the ALS cases identified by each of the sources and estimated the completeness of case ascertainment for each of the three ALS Registry sources individually, pairwise, and in all combinations. Results: Case-finding completeness was 54% in 2011 and improved to 56% in 2014. A smaller proportion of ALS patients under age 65 were ascertained than those 65 or older, and ascertainment was also lower for nonwhite than white patients. The uncorrected ALS prevalence was 4.3/100,000 in 2011 (in 2014, 5.0/100,000), but after correction for underascertainment, annual prevalence in 2011 was 7.9/100,000 (95% CI: 7.6–8.2) (in 2014 was 8.9/100,000 [95% CI: 8.7–9.2]). Discussion/Conclusion: Our findings indicate that administrative healthcare databases are a very efficient method for identifying the majority of ALS prevalent cases in the National ALS Registry and that the inclusion of a web registry portal for patients to self-register is important to ensure a more representative population for estimating ALS prevalence. Nonetheless, more than 40% of ALS cases were not ascertained by the Registry, with individuals younger than age 65 and people of color underrepresented. Recommendations are provided for additional methods that can be considered to improve the completeness of case ascertainment.

Summary Background Few studies have examined the efficacy of drug-eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure compared with bare-metal stents (BMS) in patients undergoing stenting of de-novo SVG lesions. We assessed the risks and benefits of the use of DES versus BMS in de-novo SVG lesions. Methods Patients were recruited to our double-blind, randomised controlled trial from 25 US Department of Veterans Affairs centres. Eligible participants were aged at least 18 years and had at least one significant de-novo SVG lesion (50–99% stenosis of a 2·25–4·5 mm diameter SVG) requiring percutaneous coronary intervention with intent to use embolic protection devices. Enrolled patients were randomly assigned, in a 1:1 ratio, by phone randomisation system to receive a DES or BMS. Randomisation was stratified by presence or absence of diabetes and number of target SVG lesions requiring percutaneous coronary intervention (one or two or more) within each participating site by use of an adaptive scheme intended to balance the two stent type groups on marginal totals for the stratification factors. Patients, referring physicians, study coordinators, and outcome assessors were masked to group allocation. The primary endpoint was the 12-month incidence of target vessel failure, defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation. The DIVA trial is registered with ClinicalTrials.gov, number NCT01121224. Findings Between Jan 1, 2012, and Dec 31, 2015, 599 patients were randomly assigned to the stent groups, and the data for 597 patients were used. The patients' mean age was 68·6 (SD 7·6) years, and 595 (>99%) patients were men. The two stent groups were similar for most baseline characteristics. At 12 months, the incidence of target vessel failure was 17% (51 of 292) in the DES group versus 19% (58 of 305) in the BMS group (adjusted hazard ratio 0·92, 95% CI 0·63–1·34, p=0·70). Between-group differences in the components of the primary endpoint, serious adverse events, or stent thrombosis were not significant. Enrolment was stopped before the revised target sample size of 762 patients was reached. Interpretation In patients undergoing stenting of de-novo SVG lesions, no significant differences in outcomes between those receiving DES and BMS during 12 months of follow-up were found. The study results have important economic implications in countries with high DES prices such as the USA, because they suggest that the lower-cost BMS can be used in SVG lesions without compromising either safety or efficacy. Funding US Department of Veterans Affairs Cooperative Studies Program.

Background: Persons with HIV and severe mental illness face numerous barriers in antiretroviral treatment adherence. More information is needed on reasons for loss of follow-up in this population. Methods: A retrospective analysis was conducted on adult HIV patients with a history of mental illness enrolled at an urban HIV clinic in Johannesburg, South Africa who discontinued care. Results: 24.8% of adult patients in the clinic discontinued follow-up during the study period. Of those discontinuing follow-up, 48 were successfully traced by home visits. Among this group, 21 (43.8%) were not engaged in care, 12 (25.0%) had transferred care, 9 (18.8%) were deceased, 3 (6.2%) had relocated, and 3 (6.2%) were missing. Transportation costs and distance, conflicts with work/school schedule, and confusion regarding when to return were the most frequently cited reasons for discontinuing follow-up. Conclusions: Although almost 25% of patients were lost to follow up, overall rates of retention in care for these patients were similar to those seen in other HIV-infected populations and higher than those seen among patients with psychiatric disease. Tracing patients through home visits proved to be an effective means to confirm the magnitude of patients lost to follow up, ascertain their outcomes, and elucidate the reasons for discontinuing care.

In 2009-2010, 93 cases of dengue were identified in Key West, Florida. This was the first outbreak of autochthonous transmission of dengue in Florida since 1934. In response to this outbreak, a multifaceted public education outreach campaign was launched. The aim of this study is to compare dengue prevention knowledge, attitudes, perceptions, and prevention practices among residents of subsidized public housing to the general population in Key West and to assess whether there were barriers preventing effective outreach from reaching specific vulnerable populations.A randomized population-based evaluation of knowledge, attitudes, and behaviors toward dengue prevention consisting of 521 separate household interviews was undertaken in July of 2011. A subset analysis was performed on interviews collected from 28 public housing units within four subsidized public housing complexes. Analysis was performed to determine whether knowledge, attitudes, and behaviors exhibited by public housing residents differed from the non-public housing study population.Public housing residents recalled fewer outreach materials (p=0.01) and were 3.4 times (95% confidence interval [CI] 1.4-8.3) more likely not to recall any outreach materials. Public housing residents were less likely to correctly identify how dengue transmission occurs (61% vs. 89%), where mosquitoes lay their eggs (54% vs. 85%), or to identify any signs or symptoms related to dengue (36% vs. 64%). Public housing residents were less likely to perform dengue prevention practices such as removing standing water or always using air conditioning.Examination of public housing residents identified an at-risk population that recalled less exposure to outreach materials and had less knowledge about dengue infection and prevention than the randomized study population. This provides public health systems the opportunity to target or modify future health messages and interventions to this group. Differences identified in the demographics of this population suggest that alternative methods or non-English materials may be required to reach desired outcomes.

This study examined the association of hematocrit (Hct) levels measured upon intensive care unit (ICU) admission and red blood cell transfusions to long-term (1-year or 180-day) mortality for both surgical and medical patients.Administrative and laboratory data were collected retrospectively on 2393 consecutive medical and surgical male patients admitted to the ICU between 2003 and 2009. We stratified patients based on their median Hct level during the first 24 hours of their ICU stay (Hct25.0%, 25% ≤ Hct30%, 30% ≤ Hct39%, and 39.0% and higher). An extended Cox regression analysis was conducted to identify the time period after ICU admission (0 to180, 180 to 365 days) when low Hct (25.0) was most strongly associated with mortality. The unadjusted and adjusted relationship between admission Hct level, receipt of a transfusion, and 180-day mortality was assessed using Cox proportional hazards regression modeling.Patients with an Hct level of less than 25% who were not transfused had the worst mortality risk overall (hazard ratio [HR], 6.26; 95% confidence interval [CI], 3.05-12.85; p0.001) during the 6 months after ICU admission than patients with a Hct level of 39.0% or more who were not transfused. Within the subgroup of patients with a Hct level of less than 25% only, receipt of a transfusion was associated with a significant reduction in the risk of mortality (HR, 0.40; 95% CI, 0.19-0.85; p = 0.017).Anemia of a Hct level of less than 25% upon admission to the ICU, in the absence of a transfusion, is associated with long-term mortality. Our study suggests that there may be Hct levels below which the transfusion risk-to-benefit imbalance reverses.

To the Editor: Dr Baker and colleagues reported that only 40% of US Internet users search for health information online yearly and that only 9% search for this information on a monthly basis. Industry market research studies, however, report results that differ greatly from the findings of Baker et al. Using random-digit dialing telephone methods, Cybercitizen Health found that 53% of all Internet users visited online health information sites in 2001 and that 65% did so in 2002. In addition, Cybercitizen Health found that 56% of such users accessed these sites monthly in 2001 and that 59% did so in 2002. In contrast, Baker et al found that only 22% of such users visited monthly in 2002. The Cybercitizen Health data also indicated that 30% of all Internet health information users are monthly users of the WebMD Network alone, a percentage in excess of the 22% overall that Baker et al reported. Similarly, according to published WebMD Business Intelligence figures, the WebMD network alone had 15.9 million average monthly visitors in the first quarter of 2002, again far exceeding the 12.1 million that Baker et al estimated for all Internet health sites. We believe that the methods of Baker et al were flawed due to the manner in which the information was collected. The study sample was based on an Internet panel that was given the incentive of a free WebTV offer. Less than 10% of the Internet population uses WebTV, thus making such a panel unlikely to be representative of either the online population or the population as a whole.